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<html>
    <head>
        <title>Paciente </title>
        <meta charset="UTF-8">
        <meta name="viewport" content="width=device-width">
    </head>
    <body>
        <div>Paciente</div>
        <div class="left">
            <label for="txtIdhistoriaClinica"> Id historia Clinica <span class="asterisco">*</span><input type="text" name="IdhistoriaClinica" id="txtIdhistoriaClinica" required></label></div>
        <div class="left">
            <label for="txtIdentificacion"> Id Paceinte  <span class="asterisco">*</span>  <input type="text" name="Identificacion" id="txtNombre" required></label></div>
        <div class="left">
            <label for="TxtFecha"> Diagnostico:<span class="asterisco"></span><input type="date" name="fecha_nacimiento" id="fecha_nacimiento"></label></div>
        <div class="left">
            <label for="txtTelefono_fijo"> Tratamiento: <span class="asterisco">*</span>  <input type="text" name="telefono_fijo" id="telefono_fijo" required></label></div>
        <div class="left">
            <label for="txtTelefono_movil"> Enfermedad Actual : <span class="asterisco">*</span>  <input type="text" name="telefono_movil" id="telefono_movil" required></label></div>
        <div class="left">
            <label for="txtAntecedentes_familiares">ANTECEDENTES FAMILIARES</label>
        
        <div class="left">
            <label for="txtDiabetes"><input type="checkbox" name="diabetes" id="diabetes" value="diabetes">Diabetes</label> </div>
        <div class="center">
            <label for="txtAsma"> <input type="checkbox" name="asma" id="asma" > Asma</label> </div>
        <div class="right">
            <label for="txtTuberculosis"><input type="checkbox" name="tuberculosis" id="tuberculosis" value="tuberculosis"> Tuberculosis</label> </div>
        <div class="left">
            <label for="txtCancer"><input type="checkbox" name="cancer" id="cancer" value="cancer">Cancer</label> </div>
        <div class="center">
            <label for="txtAlergia"> <input type="checkbox" name="alergia" id="alergia" value="alergia"> Alergia</label> </div>
        <div class="right">
            <label for="txtTabaquismo"><input type="checkbox" name="tabaquismo" id="tabaquismo" value="tabaquismo"> Tabaquismo</label> </div>
        <div class="left">
            <label for="txtHipertencion"><input type="checkbox" name="hipertencion" id="Hipertencion" value="hipertencion">Hipertencion</label> </div>
        <div class="center">
            <label for="txtEpilepcia"> <input type="checkbox" name="epilepcia" id="epilepcia" value="epilepcia"> Epilepcia</label> </div>
        <div class="right">
            <label for="txtAlcoholismo"><input type="checkbox" name="alcoholisto" id="alcoholismo" value="alcoholismo"> Alcoholismo</label> </div>

        <div class="left">
            <label for="txtCargo"> Antecendentes Quirurgicos <span class="asterisco">*</span> </label> <input type="text" name="cargo" id="cargo" required></div>
        
        <div class="left">
            <label for="txtGuardar"><input type="submit" name="guardar" id="guardar" value="Guardar"></label>  </div>
    </body>
</html>
